CITY UNIVERSITY OF PASAY College Of Nursing and School of Midwifery

A Case Presentation in Microbiology:

OTITIS MEDIA

PRESENTED BY: Acma, Kesia Airuh C. Gerubin, Merasol Mendoza, Almira Sarmiento, Diana May

ADVISER: Dr. Louie O. Domingo, M.D

OUTLINE FOR CASE PRESENTATION:

I. GENERAL DATA II. CHIEF COMPLAINT III. HISTORY OF PRESENT ILLNESS IV. PAST MEDICAL HISTORY V. PERSONAL/SOCIAL HISTORY VI. FAMILY HISTORY VII. IMMUNIZAYION HISTORY VIII. DEVELOPMENTAL HISTORY IX. PHYSICAL ASSESSTMENT X. DRUG STUDY XI. MANAGEMENT XII. ANATOMY AND PHYSIOLOGY XIII. PATHOGENESIS

I.

GENERAL DATA

Patient MS is a 11 year old, male, Filipino, Roman Catholic. He was born on September 28, 2002 at Cebu. He currently resides at Palgate 1 Maricaban Pasay City. He sought consultation at San Pablo Health Center last August 28, 2012.

II.

CHIEF COMPLAINT Pain at the left ear.

III.

HISTORY OF PRESENT ILLNESS Two days prior to consultation, patient complaint ear pain located at the left side associated with fever with the temperature of 39C. Patients mother gave paracetamol syrup, 250 mg per 5ml, 5ml 3x a day every 4 hours. No consultation was done. One day prior to consultation, left ear pain persisted associated with fever. No other symptoms of ear discharge, vomiting, nausea and dizziness. Due to persistence of symptoms, patient was brought to San Pablo Health Center for check-up.

IV.

PAST MEDICAL HISTORY

The patient has no record of pneumonia, hypertension, diabetes, asthma. The patient has no hospital records pertaining to serious ailments. The patient only had fever that was treated with paracetamol , cough and cold treated with cotrimoxazole. V. PERSONAL/SOCIAL HISTORY

Patient MS lived in Cebu with his grandparents until grade two and was transferred in Manila to live with his mother from grade three up to present. He studies at Maricaban Elementary School. The patient is the youngest . His mother works as a cashier at a canteen while his father was stated as deceased the patient developed an independent characteristics because of this. Patient MS was friendly, playful, obedient, and resourceful and can easily adapt/ adjust to his surroundings as a result of a frequent more exposure outside than being with his family as to what the mother had observed.

VI.

FAMILY HISTORY

The patients family have no history of asthma (-), hypertension (-), Diabetes Mellitus (-), Heart Disease (-), Cancer (-), with her mother and father side.

VII.

IMMUNIZATION HISTORY

The patients record of immunization is left in Cebu, his previous address, but the mother claims her son to be fully immunized.

VIII.

DEVELOPMENTAL HISTORY

The patient was breastfed up to two years of age. He was able to read at the age of three. The patients surrounding uses primary language only. He is exposed to other language but practiced only one. Patient does not communicate well enough with his family since he was more often with his friends and his mother and brother got jobs. Although they are exposed to unprivileged educational surrounding, the patients mother is willing to pursue his education with the help of his eldest brother. The patient often eats preservative or other readymade foods and canned goods but if not in a hurry, they prefer vegetables. IX. PHYSICAL ASSESSMENT

A. GENERAL APPEARANCE Vital Signs : RRPR 20 61 bpm Temp.- 36.5 C BP80/50

The patient is conscious, well-oriented of his present condition and showed interest with the interview by answering every question instantaneously.

The patient has no obvious physical deformities or abnormalities. The patient showed no sign or potential signs of distress.

The patient is relaxed, has an erect posture and coordinated by body movements, can freely move, flex and extend his extremities, doesnt use any assistive device and can voluntarily move.

B. CEPHALOCAUDAL PHYSICAL ASSESSMENT

SKIN : The patients skin is uniformly brown in color except in areas exposed to the sun, has no lesions or abrasions, has uniform temperature, and when pinched, the skin springs back to the previous state.

HEAD AND FACE : The patients scalp is lighter than the color of his skin and has no areas of tenderness. The hair is evenly distributed and is thick. The patient has symmetric facial movements. The patients eyebrows have evenly distributed hair, has intact skin, symmetrically aligned, and has equal movement. The conjunctiva is transparent, capillaries sometimes evident, and sclera appears white and clear. The cornea is transparent, shiny and smooth, details of iris are visible. The iris is brown, flat and round. The patients visual acuity is normal.

EAR: The patients middle part of his left ear is red in color.

NOSE: The patient has no tenderness on sinuses. The nose is in the midline, has no discharges, no nasal flaring, both nares are patent, and no bone and cartilage deviation noted on palpation.

MOUTH AND THROAT: The patients buccal mucosa is uniformly pink in color, moist, smooth, soft, glistening and elastic in texture, and has no lesions. Some of the teeth have decayed, yellowish in color , gums are pink, moist, firm, has no retraction and bleeding of gums. Tongue is pink, has thin whitish color. Uvula is positioned in the midline of soft palate. The tonsils are pink in color,and have no discharges.

NECK: The trachea is on central placement in the midline of the neck, spaces are equal on both sides. The thyroid gland is not visible in inspection, gland ascends during swallowing, no masses palpated.

CHEST (POSTERIOR AND LATERAL): Posterior thorax is asymmetric, ribs are sloped downward, and muscle development is equal. Spines are slightly aligned, are uniform in temperature, have no tenderness and masses. Chest is symmetric upon expansion.

CHEST (ANTERIOR): Breathing pattern is quiet, rhythmic and effortless. Chest is symmetric upon expansion, has flat sound on the part with heavy muscles and bony prominences, tympanic on the stomach, dullness on the liver and spleen, broncho vesicular and vesicular.

HEART: The patients heart has no palpable pulsation over the aortic, pulmonic, and mitral valves, no noted abnormal heaves, and thrills felt over the apex, and no abnormal heart sounds is heard like murmurs.

UPPER EXTREMITIES: Both extremities are equal in size, have the same contour with prominences of joints, no involuntary movement, color is even, temperature is warm and even, has equal contraction and even, can perform complete range of motion.

ABDOMEN: The patients abdomen skin color is uniform, no lesions, no scar, flat, rounded, no tenderness noted, with smooth hand consistent tension, and has no muscle guarding.

LOWER EXTREMITIES: Both extremities are equal in size, have the same contractures and tremors, normal muscle tension, adequate strength of muscle. The bones are uniform in structure, no deformities, tenderness and pain. Joints are not tender, has smooth movement and no nodules.

ANUS, RECTUM AND PROSTATE (Not Assessed)

X.

DRUG STUDY

Generic Name/Bran d Name Paracetam ol/ Tylenol

Classificatio n Analgesic (Non-opium) Antipyretics

Indication

Contraindic ation Paracetamol is contraindica ted in hypersensiti vity, analgesic nephropathy , renal and hepatic impairment.

Temporary relief of pain and discomfort from headache, fever, cold, flu, minor muscular aches, overexertion , menstrual cramps, toothache, minor arthritic pain.

Mechanis m of action Decreases fever by inhibiting the effects of pyrogens on the hypothalam ic heat regulating centers and by a hypothalam ic action leading to sweating and vasodilatio n. Relieves by inhibiting prostagland in synthesis at the CNS but does not have antiinflammator y action because of its minimal effect of peripheral prostagland in synthesis.

Adverse Reaction

Nursing Responsibilit ies Hematolo Assess the gic: patients pain hemolytic or anemia, temperature leucopenia, before therapy neutropeni and regularly a, there after pancytope nia, Assess the thrombocyt patients drug openia. history and Hepatic: calculate total liver daily dosage damage, accordingly jaundice. Metabolic: Be alert for hypoglyce signs of mia. Skin: reactions and rash, drug urticuria. interactions. Assess the patients and familys knowledge of drug therapy.

Cotrimoxaz ole

Antibacterial

Cotrimoxazo le is prescribed for pneumocysti c pneumonia, chronic bronchitis, urinary tract infection, acute ear infections in children, skin or wound infections, infections in the gastrointesti nal tract, shigellosis, and travelers diarrhea. Whipple's disease, cerebral toxoplasmos is in HIV patients, and melioidosis

Patients with certain blood conditions such as neutropenia, agranulocys tosis, a plastic or megalobasti c anemia, and thrombocyto penia MUST NOT take Cotrimoxazo le

Trimethopri m inhibits the synthesis of nucleic acids and proteins in susceptible bacteria; the bacterial enzyme involved in this reaction is more readily inhibited than the mammalian enzyme.

Dizziness Headache Loss of appetite Stomach upset (nausea, vomiting) Skin Rashes. Arthralgia an myalgia. Hematologi cal changes, reversible neutropeni a and thrombocyt openia, steven Johnson syndrome, lyells syndrome. Skin and systemic reactions.

Assess allergic reactionsMonitor I&O ratio-Monitor kidney function. Assess for signs and symptoms of anaphylaxis like wheezing, rales, tachypnea, tachycardia, facial swelling, fainting and seizures. If this are seen discontinue the drug and report to physician.

XI.

ANATOMY AND PHYSIOLOGY

A. Outer ear The outer ear acts as a funnel to conduct air vibrations through to the eardrum. It also has the function of sound localization. Sound localization for sounds approaching from the left or the right is determined in two ways. Firstly, the sound wave reaches the ear closer to the sound slightly earlier than it reaches the other ear. Secondly, the sound is less intense when it reaches the second ear, because the head acts as a sound barrier, partially disrupting the spreading of the sound waves. All these cues are integrated by the brain to determine the location of the source of the sound. It is therefore difficult to localize sound with only one ear. The outer ear consists of the pinna and the ear canal. Pinna The pinna is a prominent skin-covered flap located on the side of the head, and is the visible part of the ear externally.

Ear canal The ear canal is roughly 3cm long in adults and slightly S-shaped. Middle ear The middle ear is located between the external and inner ear. It is separated from the ear canal of the outer ear by the tympanic membrane (the eardrum). The middle ear functions to transfer the vibrations of the eardrum to the inner ear fluid. This transfer of sound vibrations is possible through a chain of movable small bones, called ossicles, which extend across the middle ear, and their corresponding small muscles. Tympanic membrane (eardrum)

The tympanic membrane is commonly known as the eardrum, and separates the ear canal from the middle ear. It is about 1cm in diameter and slightly concave (curving inward) on its outer surface. It vibrates freely in response to sound. The membrane is highly innervated, making it highly sensitive to pain. For the membrane to move freely when air strikes it, the

resting air pressure on both sides of the tympanic membrane must be equal. The outside of the membrane is exposed to atmospheric pressure (pressure of the environment in which we find ourselves) through the auditory tube, so that the cavity in which it is located, called the tympanic cavity, is continuous with the cells in the jaw and throat area. Normally, the auditory tube is flattered and closed, but swallowing, yawning and chewing pull the tube open, allowing air to enter or leave the tympanic cavity. This opening of the auditory tube allows air pressure in the middle ear to equilibrate with atmospheric pressure, so that the pressures on both sides of the tympanic membrane become equal to each other. Excessive pressure on either side of the tympanic membrane dampens the sense of the hearing because the tympanic membrane cannot vibrate freely. When external pressure changes rapidly, for example during air flight, the eardrum can bulge painfully because as the pressure outside the ear changes, the pressure in the middle ear remains unchanged. Yawning or swallowing in this instance opens up the auditory tube, allowing the pressure on both sides of the tympanic membrane to equalize, relieving the pressure distortion as the eardrum goes back into place. Since the auditory tube connects the jaw/throat areas to the ear, it allows throat infections to spread relatively easily to the middle ear.

Auditory ossicles and muscles

The tympanic cavity contains the body's three smallest bones and two smallest muscles. The bones are also referred to as auditory ossicles, and connect the eardrum to the inner ear. From the outermost to innermost, the bones are called the malleus, incus and stapes.

1. Malleus The malleus is attached to the eardrum. It has a handle that attaches to the inner surface of the eardrum, and a head that is suspended from the wall of the tympanic cavity. 2. Incus The incus is connected to the malleus on the side closer to the eardrum, and to the stapes on the side closer to the inner ear. 3. Stapes The stapes has an arch and a footplate. This footplate is held by a ringlike piece of tissue in an opening called the oval window, which is the entrance into the inner ear.

Stapedius and Tensor tympani

The stapedius is the muscle of the inner ear that inserts on the stapes. The tensor tympani s the inner ear muscle that insert on the malleus, converting sound wave vibrations into inner ear fluid movement. 4. Inner ear The inner ear is the deepest part of the whole ear, and is located in a place known as the bony labyrinth, which is a maze of bone passageways lined by a network of fleshy tubes known as the membranous labyrinth. Cochlear

Arising from the vestibule is the cochlear, which is sometimes referred to as the organ of hearing, as it is the part of the whole ear that actually converts sound vibrations to the perception of hearing.

Chambers of the cochlear The cochlear contains three fluid-filled chambers separated by membranes. The upper chamber, scala vestibule, and the bottom chamber, scala tympani, are filled with perilymph. The scala tympani is covered by a secondary tympanic membrane. The middle chamber is the scala media, or the cochlear duct. It is filled with endolymph, instead of perilymph.

1. Organ of Corti The organ of corti is supported by a membrane called the basilar membrane. It about the size of a pea, and acts as a transducer, converting vibration into nerve impulses.

XII.

MANAGEMENT

INDEPENDENT MANAGEMENT Monitored vital signs every home visit Performed physical assessment during check up and home visit Instructed the patients mother to report any discharges in the affected ear Instructed the patients mother to perform tepid sponge bath when fever occurs Instructed the patients mother how to care for the ear to prevent injury

DEPENDENT MANAGEMENT Instructed to take medication as prescribed

XIII.

PATHOGENESIS

Cause: Bacteria Virus Engorgement of the middle ear cleft lining. Middle ear air absorption Acute Inflammation of the middle ear Eustachian tube obstruction

Hyperemia of tympanic membrane Serous oxidation

Bulging tympanic membrane Exudation become purulent

Further congestion and bulging of tympanic

membrane

Tympanic membrane may be rupture

Otitis Media